Each case presents a real patient scenario with 6–7 linked clinical-judgment questions — exactly the NCSBN April 2026 NGN format. Bow-tie, matrix, cloze, trend, and extended-response items across all 6 CJMM layers.
The nurse reviews Mrs. Hayes' assessment findings. Which findings require IMMEDIATE nursing intervention?
The nurse reviews the admission assessment for this 58-year-old patient with a 3-day history of productive cough and fever.
The nurse is planning care for this patient with DKA.
The nurse is prioritizing care for Mr. Webb upon admission to the cardiac step-down unit. Select ALL nursing actions that are priority interventions for this patient at this time.
The nurse is reviewing the patient's clinical data to assist the stroke team in determining tPA eligibility. Select ALL findings from the patient's presentation that support tPA candidacy.
The nurse is assessing an 8-year-old male brought to the emergency department following allergen exposure. He has a history of moderate persistent asthma and received albuterol MDI 2 puffs at home with no relief 30 minutes before arrival. Which clinical FINDINGS from this assessment indicate an acut
The nurse is performing an assessment on Mr. Jennings, a 71-year-old male on post-operative day 2 following emergency bowel resection. Which clinical FINDINGS from the nurse's assessment are most consistent with acute kidney injury (AKI) and require immediate intervention?
The nurse assesses Maria G., a 28-year-old G3P3 who delivered vaginally 45 minutes ago. Which clinical FINDINGS from the nurse's assessment indicate active postpartum hemorrhage with hemodynamic instability?
The nurse is reviewing the initial assessment data for the 34-year-old male. Which FINDINGS from the patient's presentation represent the HIGHEST-risk factors that increase his likelihood of a future suicide attempt?
The nurse is completing the initial assessment of a 78-year-old nursing home resident with a 3-day history of productive cough and fever. Which clinical FINDINGS indicate acute illness severity requiring immediate escalation of care?
The nurse is reviewing the patient's presentation to determine whether this represents a hypertensive EMERGENCY or hypertensive urgency. Select ALL findings from the patient's assessment that specifically indicate this is a hypertensive EMERGENCY rather than urgency.
The nurse is planning care for a patient admitted with severe acute pancreatitis (RANSON score 4). Which interventions are indicated?
The nurse reviews the assessment data for this 6-year-old brought to the ED with fever, headache, and neck stiffness.
The nurse is planning post-procedure care for this patient following femoral artery PCI. Select ALL assessments and interventions that are essential in the immediate post-catheterization period.
The nurse assesses the 48-year-old patient who was admitted 36 hours ago for pneumonia and has a history of heavy alcohol use.
The nurse is assessing a 38-year-old female with known Graves' disease following appendectomy. She stopped taking propylthiouracil (PTU) 3 weeks ago. Which clinical findings are MOST consistent with thyroid storm (thyrotoxic crisis)?
The nurse is assessing a 69-year-old male with GOLD Stage III COPD presenting with worsening dyspnea over 4 days. Which clinical findings are consistent with acute hypercapnic respiratory failure requiring immediate intervention?
The nurse is preparing to care for the burn patient immediately upon arrival.
The nurse is assessing a 24-year-old female with sickle cell disease (HbSS) admitted for vaso-occlusive crisis triggered by dehydration. Which clinical findings indicate the need for immediate priority nursing interventions?
The nurse is reviewing the clinical findings for this 52-year-old post-surgical patient. Which findings indicate HIGH-RISK (massive) pulmonary embolism requiring urgent intervention? Select ALL that apply. A. Systolic blood pressure 88/52 mmHg despite 2L IV fluid resuscitation B. SpO2 88% on room a
CJMM Skill: Recognize Cues The nurse reviews Maya's initial assessment data collected at 0700—0800. Select ALL findings that are abnormal and require immediate nursing action or provider notification.
The nurse is triaging Liam upon arrival. Which findings from the assessment are consistent with the diagnosis of moderate diabetic ketoacidosis (DKA) in a pediatric patient?
The NICU nurse completes the initial assessment of the 28-week neonate on arrival. Select ALL findings that indicate significant respiratory distress requiring immediate intervention.
The nurse completes the admission assessment for Marcus. Select ALL findings that are consistent with an acute manic episode and require immediate nursing intervention.
The nurse is performing the initial assessment on arrival. Select ALL findings that confirm the opioid toxidrome and require immediate intervention.
The nurse is reviewing the assessment findings for the 58-year-old male presenting with suspected STEMI. Select ALL findings that the nurse should recognize as clinical cues consistent with an anterior STEMI requiring immediate intervention.
The nurse is reviewing the patient's initial assessment findings.
The nurse completes the admission assessment of Marcus T. Select ALL findings that indicate decompensated liver failure with an active complication.
Marcus arrives with BP 82/48 mmHg, HR 48 bpm, warm/dry skin below the injury, and SpO2 92%. The trauma nurse must differentiate neurogenic shock from hemorrhagic shock to guide treatment. Select ALL findings that distinguish neurogenic shock FROM hemorrhagic shock in this patient.
The nurse is reviewing the assessment data for this patient. Select ALL findings that are consistent with delirium rather than dementia, and that require immediate nursing assessment and intervention.
The nurse reviews the patient's report during the phone call and clinic assessment findings. Select ALL findings that indicate acute heart failure exacerbation requiring immediate clinical intervention.
The nurse completes the initial assessment of Mrs. Holloway during check-in. Select ALL findings that indicate hypoglycemia requiring immediate treatment.
The nurse reviews Mr. M.'s clinical profile at 0300. Select ALL patient factors that contribute to his HIGH fall risk and require nursing action.
The nurse is reviewing Mr. Jenkins' wound assessment findings. Which findings indicate wound infection that requires intervention BEYOND topical wound care alone?
The nurse is reviewing Mr. Webb's risk factors for deep vein thrombosis using Virchow's Triad as a clinical framework. Select ALL factors from the patient's history and presentation that contribute to his highest-risk DVT classification.
The nurse reviews the initial assessment findings for this 27-year-old patient. Select ALL findings that suggest ectopic pregnancy and require immediate clinical evaluation.
The nurse performs a rapid assessment of the 3-year-old brought to the pediatric ED by his parents.
The nurse is completing the initial assessment. Select ALL findings that indicate acute psychotic decompensation requiring immediate psychiatric intervention.
The nurse completes the 6-hour neurovascular assessment of Marcus's right lower extremity. Select ALL findings that indicate developing acute compartment syndrome requiring immediate intervention.
The nurse reviews the infant's assessment data and laboratory results. Select ALL findings that indicate this infant requires phototherapy rather than observation alone.
[NURSE'S NOTES] Marcus Williams is a 58-year-old male, day 10 post-chemotherapy (R-CHOP) for diffuse large B-cell lymphoma. Admitted 6 hours ago with febrile neutropenia (ANC 320/mm³, T 38.9°C). Started on piperacillin-tazobactam 4.5 g IV q6h per neutropenic fever protocol. Blood cultures drawn x2 p
[NURSE'S NOTES] Sophia Chen is a 7-month-old female (pre-illness weight 7.6 kg, current weight 6.8 kg — 10.5% weight loss) brought to the pediatric ED with severe dehydration secondary to viral gastroenteritis (4 days of vomiting and diarrhea). Breastfed exclusively. Last wet diaper >10 hours ago. A
Marcus Thompson is a 45-year-old male admitted to the ICU after aspiration of gastric contents during emergent intubation for altered mental status. PMH: alcohol use disorder, hypertension. He is on mechanical ventilation: AC/VC mode, TV 550 mL, RR 16, PEEP 14 cmH2O, FiO2 0.72. Weight 90 kg, IBW 75
Dorothy Simmons is a 58-year-old female on POD2 after partial bowel resection for Stage II colon cancer. PMH: hypertension on hydrochlorothiazide 25 mg daily. She received bowel prep and was NPO pre-op. Post-op she has morphine PCA and ondansetron. Vital signs: BP 128/78, HR 92, Temp 37.6°C, SpO2 97
James Washington is a 67-year-old male with 12-year history of CKD from T2DM and hypertension, on three-times-weekly hemodialysis. He missed Wednesday and Friday sessions and presents Sunday with dyspnea and bilateral leg swelling. Medications: amlodipine 10 mg, carvedilol 25 mg BID, sevelamer 1600
Priya Patel is a 34-year-old with autoimmune Addison's disease on hydrocortisone 20 mg AM/10 mg PM and fludrocortisone 0.1 mg daily. She presents via EMS after her husband found her unresponsive. She had nausea, vomiting, and diarrhea for 3 days and could not keep any medications down. She did NOT f
Bernard Collins is a 72-year-old male with Stage IIIA SCLC on cisplatin/etoposide. He was started on carbamazepine 400 mg BID 3 months ago for chemotherapy-induced peripheral neuropathy. He presents with 48 hours of confusion, nausea, headache, and one episode of vomiting. No diarrhea, no edema, wei
Tyler Morrison is a 19-year-old male with newly diagnosed Stage IV Burkitt lymphoma (bone marrow involvement). Started R-CODOX-M chemotherapy 18 hours ago. Allopurinol started only 12 hours before chemo (optimal 48-72 hours). Severe muscle cramps, nausea, anxiety. Vital signs: BP 108/72, HR 118, RR
Robert Chen is a 52-year-old male with poorly controlled hypertension and Marfan syndrome features (tall, long limbs, high-arched palate). He presents with sudden-onset tearing chest pain radiating to his mid-back, instantly at maximum intensity 45 minutes ago. Diaphoretic and in severe distress. Vi
Amanda Rodriguez is a 28-year-old female on TMP-SMX double-strength for UTI for 12 days. She presents with 5-day progressive painful skin lesions, sore throat, painful eyes, and difficulty swallowing. Vital signs: BP 108/72, HR 118, RR 22, Temp 38.6°C, SpO2 96% on RA. Exam: blistering/epidermal deta
Derek Williams is a 22-year-old male found unresponsive at a party where friends report he used alcohol and MDMA and danced intensely for hours in a warm room without adequate water. Alert but confused on EMS arrival. Severe diffuse muscle pain, unable to walk. Vital signs: BP 92/60, HR 126, RR 20,
Jasmine Torres is a 16-year-old female with severe persistent asthma, multiple prior ICU admissions and one prior intubation. Current medications: fluticasone/salmeterol, montelukast, albuterol PRN. She triggered an attack during PE class. EMS administered three albuterol nebs with no improvement. O
Harold Foster is a 65-year-old male with Stage IV NSCLC with pericardial metastases. He presents with 3-day progressive dyspnea at rest. No chest pain. Vital signs: BP 82/60, HR 118, RR 24, SpO2 93% on 2L NC. JVD at 8 cm above sternal angle, heart sounds barely audible/muffled. Pulsus paradoxus: 18
Marcus Jennings is a 34-year-old male brought by EMS after a high-speed MVC. He was an unrestrained driver. GCS 12. Vital signs: BP 72/44, HR 138, RR 28, Temp 35.1°C (hypothermic), SpO2 94% on 15L NRB. Skin: pale, cool, mottled extremities. FAST exam: free fluid in Morrison's pouch, perisplenic, and
Sofia Martinez is a 32-year-old G2P1 at 36 weeks with pregnancy-induced hypertension and smoking history (1 ppd). Sudden-onset severe abdominal pain and vaginal bleeding at home 30 minutes ago. BP 142/94, HR 126, RR 22, SpO2 97%. Uterus: board-like rigidity, no relaxation between contractions (tetan
Rachel Kim is a 27-year-old G1P0 at 39 weeks gestation admitted for induction of labor for post-dates pregnancy. Her cervix was 3 cm dilated, 80% effaced, -2 station. The obstetrician performed AROM (artificial rupture of membranes) using an amnihook. Approximately 1,000 mL of clear amniotic fluid g
Amara Johnson is a 29-year-old G1P0 at 34+2 weeks gestation with no prior prenatal complications. She presents to triage with severe headache (7/10), 'spots in my vision' (scotoma), and epigastric/right upper quadrant pain for 3 hours. BP on arrival: 172/110 mmHg. Repeat BP 10 minutes later: 168/106
Keisha Thompson is a 26-year-old G2P2 who underwent emergency C-section 3 days ago for failure to progress after 22 hours of labor. She had prolonged rupture of membranes (18 hours), multiple vaginal examinations (8 during labor), and required internal fetal monitoring. Her delivery was complicated
Elijah Brown is a 4-year-old unvaccinated male (parents declined Hib vaccine) brought to the ED by his parents after sudden onset of fever, severe sore throat, and difficulty breathing starting 3 hours ago. He is sitting bolt upright, leaning forward on both hands with his neck extended (tripod/snif
Carlos Rivera is a 3-year-old male brought to the pediatrician for 8 consecutive days of high fever (39.1-40.2°C) unresponsive to antipyretics. His mother reports he has been irritable and 'not himself.' On examination: bilateral non-exudative conjunctival injection; oral mucosa shows strawberry ton
Emma Chen is a 5-year-old female brought to the pediatrician by her mother who noticed 'puffy eyes' for the past week. The puffiness is worse in the morning and improves slightly during the day. She has developed a progressively distended abdomen and visible swelling of her legs. She had a URI 2 wee
Sophia Martinez is a 9-year-old female diagnosed with polyarticular JIA (rheumatoid factor negative) 2 years ago. She has symmetric involvement of the small joints of both hands and feet, bilateral wrists, and bilateral knees. She is ANA positive. Current medications: methotrexate 15 mg/m² PO weekly
Taylor Nguyen is a 17-year-old female admitted to the inpatient eating disorders unit after her school counselor noted marked weight loss over 8 months. Her parents report she has been restricting all intake to <400 kcal/day for 4 weeks. Tallent: 5'5". Current weight: 41 kg. BMI: 13.8 kg/m² (severel
Margaret Wilson is a 52-year-old female brought to the psychiatric ED by her daughter after the daughter found her giving away her jewelry, cleaning out her closets, and 'saying goodbye' to family photos. Margaret has a 20-year history of major depressive disorder, managed outpatient with sertraline
James Parker is a 38-year-old male with depression and chronic low back pain. He takes sertraline 150 mg daily and tramadol 50 mg four times daily. He is hospitalized for MRSA wound infection and started on linezolid 600 mg IV q12h (a monoamine oxidase inhibitor class antibiotic). Twenty-four hours
Robert Torres is a 45-year-old male with anxiety disorder, managed with alprazolam (Xanax) 4 mg/day in divided doses for 10 years. He lost his prescription 2 days ago and has been unable to obtain a refill. He presents to the ED with tremors, diaphoresis, anxiety, hypertension BP 172/106, HR 118, te
Harriet Johnson is an 81-year-old female with a history of osteoporosis, atrial fibrillation (on warfarin), and mild cognitive impairment (baseline MMSE 22/30). She fell at home and sustained a right femoral neck fracture. She underwent right hip hemiarthroplasty under spinal anesthesia. Pre-operati
William Brown is a 79-year-old male with ischemic cardiomyopathy, EF 15%, NYHA Class IV HF, and a dual-chamber ICD/CRT device implanted 4 years ago. He is admitted for the 4th time in 3 months for fluid overload (weight gain 7 kg, SpO2 88% on 3L NC, BNP 8,400 pg/mL). His medications include maximall
George Miller is a 78-year-old male with moderate Alzheimer's disease (MMSE 14, baseline 16) living with his wife. He is admitted for a urinary tract infection causing worsening confusion. His wife reports he has baseline sundowning — increased agitation and confusion in the late afternoon and eveni
Dorothy Peterson is a 71-year-old female with GOLD Stage IV COPD (FEV1 28% predicted), former 50 pack-year smoker (quit 3 years ago), who lives alone in a first-floor apartment. She has one son who lives 2 hours away. She uses a rollator walker for mobility and requires home oxygen at rest. She pres
Patricia Evans is a 68-year-old female with a bioprosthetic mitral valve replacement 8 years ago complicated by multiple valve thromboses, leading to a mechanical valve replacement 4 years ago. She has been on warfarin 7.5 mg daily (target INR 2.5-3.5 for mechanical valve). She presents to the antic
Raymond Davis is a 56-year-old male who underwent 4-vessel CABG surgery 7 days ago for multivessel coronary artery disease. Post-operatively, he received unfractionated heparin (UFH) 5,000 units subcutaneous q8h for DVT prophylaxis. Post-op labs were monitored: platelets Day 1: 212,000; Day 3: 182,0
Emily Chen is a 19-year-old female brought to the ED by her roommate after she found Emily crying and confessing to ingesting 'all her Tylenol' approximately 6 hours ago. She has no prior psychiatric history. She is tearful but cooperative. She ingested 50 tablets of 500 mg acetaminophen (Tylenol) w
Walter Johnson is a 72-year-old male with Stage 3 CKD (creatinine 1.8 mg/dL, eGFR 38 mL/min), T2DM managed with metformin 1000 mg BID, and recently diagnosed stable multivessel coronary artery disease on cardiac catheterization referral. He takes: metformin 1000 mg BID, lisinopril 20 mg daily, atorv
Marcus Williams is a 66-year-old male admitted 14 days ago for a left middle cerebral artery (MCA) ischemic stroke. He received IV tPA in the ED and was transferred to the stroke unit. He has right-sided hemiplegia (face, arm, and leg), Broca's aphasia (understands language but cannot produce meanin
David Park is a 58-year-old male who underwent emergency left-sided descending colostomy and Hartmann's procedure for perforated sigmoid diverticulitis with abscess formation (later found to be cancer). He had no pre-operative ostomy education due to the emergent nature of surgery. His wife is suppo
James Thomas is a 34-year-old homeless male who presents to the free TB clinic with 3 months of productive cough (yellow sputum, occasionally blood-tinged), drenching night sweats, and 20-lb weight loss. He is HIV-positive (CD4 220, not yet on antiretroviral therapy). He has had no prior TB treatmen
Linda Morrison is a 52-year-old female discharged home after hospital management of right tibia osteomyelitis with a right arm PICC line (size: 4 French, single lumen, tip confirmed in distal SVC by CXR prior to discharge). She is receiving vancomycin 1250 mg IV q12h. She has no prior central line e
Marcus is a 71-year-old male admitted 2 days ago for a UTI. History: type 2 diabetes (A1C 9.1%), CKD stage 3 (baseline creatinine 1.6 mg/dL). Started on IV ceftriaxone. At 0615 the day nurse assesses: T 38.9°C (was 37.6°C at midnight), HR 118 bpm (was 88), BP 96/58 mmHg (was 128/76), RR 24, SpO2 93%
Diana’s current situation: new AF with RVR, BP 102/66, EF 45%, post-NSTEMI + DES day 2.
Elijah is a 9-year-old male (28 kg) with no PMH. Mother reports 2 days of vomiting, polydipsia, polyuria, and now confusion. T 37.8°C, HR 138, RR 30 (deep, sighing), BP 88/54, SpO2 98%, glucose 684 mg/dL, capillary refill 3.5 sec, dry mucous membranes, fruity breath, confused. ABG: pH 7.09, PaCO2 18
CASE 1 — Mrs. Gloria Mendez, 64-year-old female with T2DM, hypertension, hyperlipidemia. 90 minutes of substernal chest pressure radiating to jaw and left arm, diaphoresis, nausea. BP 82/50, HR 118 (sinus tachycardia), RR 28, SpO2 88% (room air), T 36.9C. ECG: ST elevation 3-4 mm in V1-V4; reciproca
CASE 2 — Mr. David Park, 52-year-old male, no PMH. Admitted 3 days ago for aspiration pneumonia after witnessed seizure. Intubated in ED. ICU Day 3: Mode Volume Control AC, Vt 550 mL, FiO2 0.80, PEEP 8, RR set 16 (total 22 — patient triggering 6 extra breaths). ABG: pH 7.30, PaCO2 52, PaO2 58, HCO3
CASE 3 — Ms. Tamika Brooks, 28-year-old, G1P0. PMH: Chlamydia treated 3 years ago. Urine hCG positive, LMP 7 weeks ago. Sudden onset severe left lower quadrant pain 9/10, referred left shoulder pain, one episode of syncope. BP 74/42, HR 148, RR 26, SpO2 94% (15L NRB). Abdomen: rigid, exquisitely ten
CASE 4 — Baby Elias, 18-day-old male neonate. GBS status unknown. Parents report 12-hour history: not eating, very sleepy, one episode of whole-body stiffening lasting 45 seconds, and a high-pitched cry. Fontanelle looks 'puffier than normal.' T 38.9C (rectal), HR 192 bpm, RR 58, SpO2 94% (room air)
CASE 5 — Mr. Jerome Ellis, 34-year-old male with HbSS (sickle cell disease). Hydroxyurea 1,500 mg daily, folic acid. 3-day bilateral thigh/lumbar/knee pain 10/10. Today: chest pain, SOB, new fever, cough. BP 128/82, HR 114, RR 28, T 38.7C, SpO2 88% (room air). CXR: NEW bilateral lower lobe infiltrat
CASE 6 — Ms. Priya Sharma, 42-year-old female. PMH: Combined OCP (3 years), Factor V Leiden heterozygous, BMI 32. Three weeks ago: 11-hour flight. 4-day right calf pain/swelling, then today sudden severe dyspnea, pleuritic right chest pain, hemoptysis (blood-streaked sputum). BP 106/68, HR 126, RR 3
CASE 7 — Mr. Derek Lawson, 22-year-old male, collegiate football player. Diving into shallow pool → flexion-compression injury. BP 78/44, HR 48 (bradycardia), RR 14 (shallow), T 35.4C. SpO2 88% on 100% O2 via BVM. Complete motor and sensory paralysis all four limbs (quadriplegia). Loss of sensation
CASE 8 — Lily Chen, 4-year-old female. Incomplete vaccinations (parents declined Hib vaccine). 6-hour rapid progression: sore throat → drooling → high fever → difficulty swallowing → tripod position. T 40.1C, HR 168, RR 38, SpO2 93% on room air. Toxic appearance; tripod position (leaning forward, ha
CASE 9 — Mrs. Layla Haddad, 32-year-old, G3P2. PMH: Chronic hypertension (labetalol 200 mg BID). Lost to follow-up after 22 weeks. Currently 34 weeks. Smokes 1/2 PPD throughout pregnancy. Sudden 'board-like' abdominal pain with no relief between contractions. Significant vaginal bleeding. BP 168/114
CASE 10 — Mr. Andres Cordero, 48-year-old male. PMH: Alcohol use disorder (daily drinking since age 28; approximately 750 mL vodka/day), hypertriglyceridemia (TG 2,140 last year), obesity BMI 38. No medications. Severe epigastric and periumbilical pain radiating to back (9/10), onset 12 hours ago af
CASE 11 — Ms. Heather Brandt, 38-year-old female, bipolar disorder type I. Medications: lithium carbonate 900 mg BID (6 years), levothyroxine 88 mcg, lisinopril 10 mg daily (started 2 months ago for hypertension). Husband: 'She's been confused and trembling all day and vomited three times.' Lithium
CASE 12 — Maya Johnson, 11-year-old, newly diagnosed Type 1 DM. Parents noted 3 weeks of polyuria, polydipsia, weight loss. Today: lethargic, vomiting, Kussmaul respirations (deep, rapid). Glucose 648 mg/dL, pH 7.12, HCO3 8, pCO2 18, Na+ 128 (corrected ~137), K+ 5.8 mEq/L. Large urinary ketones. Wei
CASE 13 — Mr. Samuel Oduya, 58-year-old male. PMH: Uncontrolled hypertension, Marfan syndrome features. Sudden onset 'worst pain of my life' — tearing, ripping quality, radiating to back between shoulder blades. BP: RIGHT arm 198/114, LEFT arm 142/88 (pulse deficit >20 mmHg). HR 108, SpO2 94% (RA),
CASE 14 — Mrs. Dorothy Evans, 78-year-old female. PMH: COPD (GOLD Stage 2), Type 2 DM, hypertension, osteoporosis. Lives alone. Medications: tiotropium, fluticasone/salmeterol, metformin, lisinopril, alendronate. 4-day productive cough, fever 39.4C, INCREASING CONFUSION (MMSE baseline 29/30; today 2
CASE 15 — Mr. Patrick Sullivan, 52-year-old male. PMH: Alcohol use disorder (daily drinking since age 28; approximately 750 mL vodka/day). Admitted for elective hernia repair 36 hours ago. Surgical team did NOT obtain alcohol history. Surgery uneventful. NPO post-op. PRESENTING at 36 hours post-op:
Mrs. Carmela Russo is a 67-year-old female with T2DM and hypertension who presented with anterior STEMI. She underwent successful primary PCI (LAD stented, TIMI 3 flow restored) and is now in the cardiac ICU on dobutamine 5 mcg/kg/min and norepinephrine 0.08 mcg/kg/min. She is 12 hours post-PCI.
Ms. Aaliyah Washington is a 28-year-old G1P0 who presented with acute right lower quadrant pain and a β-hCG of 4,820 mIU/mL. She underwent emergency right salpingectomy for confirmed ruptured ectopic pregnancy (the left adnexal mass seen on ultrasound was a hemorrhagic ovarian cyst). Estimated intra
Baby Marcus is a 12-day-old male born at 38 weeks gestation via prolonged labor with ruptured membranes for 22 hours. He was admitted to the NICU on day 1 with fever (38.6°C), poor feeding, and irritability. CSF analysis confirmed GBS (Group B Streptococcal) bacterial meningitis: CSF WBC 2,840, prot
Mr. Tyler Rhodes is a 22-year-old male brought in by EMS after a diving accident into a shallow pool. He is alert and oriented. He has no motor function below the shoulders, no sensation below the clavicle, and priapism is noted. Vitals: BP 78/44, HR 48 bpm, Temperature 35.4°C. He is warm, pink, and
Mrs. Fatima Al-Rashid is a 31-year-old G2P1 at 34 weeks gestation who presented with sudden-onset severe abdominal pain, vaginal bleeding, and a rigid, board-like abdomen. She underwent emergency cesarean section for severe placental abruption with Category III fetal heart tracing. Her baby was deli
Mr. Roberto Vasquez is a 46-year-old male admitted for severe necrotizing pancreatitis from hypertriglyceridemia (TG 4,820 mg/dL) and chronic alcohol use. He is on day 5 of treatment. TG have decreased to 820 mg/dL with insulin infusion. Pain is controlled. He was started on nasojejunal tube feeds o
Ms. Claire Novak is a 38-year-old female with bipolar I disorder on lithium carbonate 900 mg BID for 6 years. She was started on lisinopril 10 mg daily 2 months ago for new hypertension. She presented with confusion, coarse tremor, vomiting, and ataxia. Lithium level on admission was 3.4 mEq/L (ther
Vanessa Torres is a 38-year-old female who presents via EMS after collapsing at work. She flew home from a 14-hour international flight 48 hours ago. She is on combined oral contraceptive pills and smokes 0.5 PPD. Arrival: BP 82/54 mmHg, HR 132, RR 28, SpO₂ 84% on room air → 91% on 15 L/min NRB, GCS
Jerome Elliott is a 67-year-old male, POD #7 following 3-vessel CABG. He has been on UFH flush protocols and subcutaneous prophylactic UFH 5,000 units TID since surgery. Morning labs today: Platelets 62,000/mm³ (POD 0: 220,000 → POD 5: 148,000 → POD 6: 89,000 → POD 7: 62,000). New right arm swelling
Amelia Okonkwo is a 26-year-old G2P1 at 33+4 weeks gestation who presents after a witnessed tonic-clonic seizure at home lasting approximately 90 seconds. She had no prenatal care before 28 weeks. BP 5 days ago was 148/96 at prenatal visit. Husband reports severe headache for 24 hours, visual change
Noah Castillo is an 18-month-old male brought to the pediatric ED by his mother's boyfriend, who states, 'He fell off the couch while I was watching him.' The child's records show two prior ED visits. Assessment: Weight 11.2 kg (25th percentile), GCS 11, VS: BP 90/58, HR 148, RR 26, Temp 37.0°C, SpO
Darnell Washington is a 58-year-old male with CKD 3b (baseline creatinine 2.8, baseline K+ 4.8), T2DM, and HTN admitted for an infected diabetic foot ulcer. Home medications continued: lisinopril 20 mg daily, spironolactone 25 mg daily, insulin glargine. Current IV antibiotic: TMP-SMX for MRSA foot
Sofia Reyes is a 24-year-old female with no significant PMH who presents with a 5-day history of nausea, vomiting, jaundice, and confusion. Roommate found an empty bottle of extra-strength acetaminophen (500 tablets, recently purchased). Sofia is disoriented to time and place (GCS 12, E3V3M6). VS: B
Marcus Webb is a 29-year-old male with a C6 ASIA A (complete) spinal cord injury from a diving accident 6 weeks ago. He is in the rehabilitation unit using an indwelling Foley catheter. At 1430, the nurse finds him flushed and diaphoretic in his power wheelchair with a '10/10 headache' and nausea. V
Ingrid Larsson is a 67-year-old female with COPD (GOLD Stage III), obesity (BMI 42), and OSA. She underwent a surgical tracheostomy on hospital day 5 following prolonged intubation for a COPD exacerbation. Her tracheostomy is now 10 days old (cuffed, size 8 Shiley). She is on a tracheostomy collar w
Kevin Park is a 28-year-old male with no significant PMH presenting for elective ACL repair. Anesthesia was induced with propofol and succinylcholine, and maintenance was started with sevoflurane (an inhaled halogenated anesthetic). Approximately 25 minutes into the procedure: ETCO₂ has risen from 3
Claudette Monroe is an 82-year-old female with T2DM (A1C 9.8%), vascular dementia (moderate), HTN, and PVD. She is mostly bedbound at a LTCF. She is transferred to the ED after 48 hours of increasing lethargy and a new Stage 4 sacral wound: 10 cm × 8 cm × 3.5 cm deep, foul odor, black eschar in cent
Renata Osei (42F, bipolar I on lithium 900mg BID for 6 years, lisinopril 10mg daily) is on hospital day 3. She developed nausea, vomiting x4, diarrhea and has eaten/drunk very little for 48 hours. VS: BP 102/64, HR 96, SpO₂ 97%, GCS 12 — confused, slurred speech. Tremor: COARSE RESTING tremor. DTRs:
Baby Olivia Chen is an 18-hour-old female neonate. GBS status: POSITIVE on maternal culture at 36 weeks. IAP: penicillin G given only 2.5 hours before delivery (adequate prophylaxis requires ≥4 hours). Membranes ruptured 19 hours before delivery. Maternal fever during labor: 38.3°C. At 18 hours of l
DeShawn Miller is a 34-year-old male with sickle cell disease (HbSS) admitted for an elective red blood cell exchange transfusion. A second unit is infusing (started 20 minutes ago at 125 mL/hr). With approximately 120 mL infused, DeShawn calls the nurse: 'Something is wrong — I have a crushing pain
Gabriel Santos is a 67-year-old male with 22-year history of type 2 diabetes (HbA1c 10.8%), PAD (ABI 0.58 bilaterally), and peripheral neuropathy (absent 10-gram monofilament bilateral feet). He presents to the wound care clinic because his wife noticed his left foot is 'red and swollen' and he feel
Miriam Goldstein is a 72-year-old female who presents to the ED with severe pain in her right eye for 4 hours, blurry vision, and a horrible headache with nausea. She vomited twice at home. PMH: Hypertension (metoprolol 50 mg daily), hyperopia corrected with +4.5 OD lenses. Currently taking OTC diph
Terrence Cole is a 16-year-old male brought to the ED at 2:15 AM. He woke from sleep 2.5 hours ago with sudden onset of severe right scrotal pain. He denies trauma, sexual activity, and urinary symptoms. He has had two prior episodes of sudden scrotal pain that resolved spontaneously. Assessment: VS
TREND ANALYSIS: Florence receives 3% hypertonic saline and benzodiazepine withdrawal protocol. Sodium correction trend: 0hr: Na 108, GCS 10, CIWA-Ar 16 4hr: Na 113, GCS 11, CIWA-Ar 12 (+5 mEq/L) 8hr: Na 116, GCS 13, CIWA-Ar 9 (+8 mEq/L) 12hr: Na 118, GCS 14, CIWA-Ar 7 (+10 mEq/L, infusion slowed) 24
Patricia Wells is a 51-year-old female with a 6-year history of idiopathic pulmonary arterial hypertension (iPAH), managed on ambrisentan (endothelin receptor antagonist, 10 mg daily) and tadalafil (PDE-5 inhibitor, 40 mg daily). She presents to her cardiology clinic reporting 3 weeks of worsening d
Alejandro Vega is a 72-year-old male with a history of atrial fibrillation (on warfarin, last INR 2 weeks ago was 1.6 — sub-therapeutic), hypertension, and prior MI (LAD stent 4 years ago). He presents via EMS for severe abdominal pain for the past 3 hours, rated 9/10, described as 'cramping everywh
Josephine Carter is a 29-year-old G3P2 female at 34+4 weeks gestation admitted for painless vaginal bleeding. She reports waking from sleep with 'a gush of bright red blood' that soaked two pads within 15 minutes. No contractions, no pain, no rupture of membranes. Prior two cesarean deliveries (both
[NURSE'S NOTES] Patient: Carmen Delgado, 28-year-old female Setting: Nephrology Clinic → Hospital Admission Clinical Context: Carmen Delgado is a 28-year-old female with systemic lupus erythematosus (SLE) diagnosed 4 years ago, currently on hydroxychloroquine 400 mg daily and low-dose prednisone 5 m
Tobias Freeman is a 41-year-old male construction worker brought in by EMS after a partial building collapse entrapped his bilateral lower extremities under heavy concrete debris for approximately 3.5 hours before rescue. EMS: BP 88/52 pre-extrication; HR 128; 2 large-bore IVs placed; 2L NS bolused.
[NURSE'S NOTES] Patient: Claudette Monroe, 82-year-old female Setting: Long-Term Care Facility → Emergency Department → Medical ICU Clinical Context: Claudette Monroe is an 82-year-old female with a history of type 2 diabetes (A1C 9.8%), vascular dementia (moderate stage), HTN, and PVD. She is a res
Sylvia Park is a 27-year-old G1P1 who delivered her son (James, 3.4 kg, Apgar 9/9) by SVD 4 days ago — uncomplicated delivery. Husband calls on day 4 postpartum: 'She hasn't slept in 3 days. She says she's receiving messages from God that the baby is in danger. Last night she was talking to people w
Emmett Rivera is a 28-year-old male with cystic fibrosis (homozygous F508del) on elexacaftor/tezacaftor/ivacaftor (Trikafta) for 14 months — FEV₁ improved from 52% to 71% predicted. He presents for hospital admission with 3 weeks of worsening dyspnea, increased green sputum production, decreased exe
Naomi Watkins is a 58-year-old female with hypertension (poorly controlled — last BP 178/106), hyperlipidemia, and Marfan syndrome (confirmed FBN1 mutation). She presents via EMS: 'worst pain of my life' — sudden onset, tearing quality, radiating from chest to back between the shoulder blades. Onset
Leo Marchetti is a 45-year-old male with 14-year history of epilepsy (focal onset with secondary generalization) on levetiracetam 1,500 mg BID. He presents via EMS after a generalized tonic-clonic seizure that started 22 minutes ago and has not stopped. His partner reports Leo has not taken his leve
[NURSE'S NOTES] Patient: Vanessa Torres, 38-year-old female Setting: Emergency Department → Medical ICU Clinical Context: Vanessa is a 38-year-old female who presents via EMS after collapsing at work. She flew home from a 14-hour international flight 48 hours ago. She reports 3 days of progressive d
[NURSE'S NOTES] Patient: Jerome Elliott, 67-year-old male Setting: Surgical Step-Down Unit, Post-Op Day 7 from CABG Clinical Context: Jerome is a 67-year-old male, POD #7 following 3-vessel CABG for triple-vessel coronary artery disease. He has been on unfractionated heparin (UFH) flush protocols an
[NURSE'S NOTES] Patient: Amelia Okonkwo, 26-year-old female, G2P1 Setting: Labor and Delivery Unit → Obstetric ICU Clinical Context: Amelia is a 26-year-old G2P1 at 33+4 weeks gestation who presents after a witnessed tonic-clonic seizure at home lasting approximately 90 seconds. EMS was called. She
[NURSE'S NOTES] Patient: Noah Castillo, 18-month-old male Setting: Pediatric Emergency Department Clinical Context: Noah is an 18-month-old male brought to the pediatric ED by his mother's boyfriend, who states, "He fell off the couch while I was watching him — he landed on his head and started cryi
[NURSE'S NOTES] Patient: Darnell Washington, 58-year-old male Setting: Medical Step-Down Unit Clinical Context: Darnell Washington is a 58-year-old male with a history of stage 3b CKD (baseline creatinine 2.8 mg/dL, baseline K+ 4.8 mEq/L), T2DM, and hypertension. He was admitted yesterday for manage
[NURSE'S NOTES] Patient: Sofia Reyes, 24-year-old female Setting: Emergency Department → Medical ICU Clinical Context: Sofia Reyes is a 24-year-old female with no significant past medical history who presents to the ED with a 5-day history of nausea, vomiting, jaundice, and confusion. Her roommate r
[NURSE'S NOTES] Patient: Marcus Webb, 29-year-old male Setting: Rehabilitation Unit Clinical Context: Marcus Webb is a 29-year-old male who sustained a C6 ASIA A (complete) spinal cord injury in a diving accident 6 weeks ago. He has no voluntary motor function or sensation below the C6 level. He is
[NURSE'S NOTES] Patient: Ingrid Larsson, 67-year-old female Setting: Medical-Surgical / Step-Down Unit Clinical Context: Ingrid Larsson is a 67-year-old female with a history of COPD (GOLD Stage III), obesity (BMI 42), and obstructive sleep apnea. She underwent a surgical tracheostomy on hospital da
[NURSE'S NOTES] Patient: Kevin Park, 28-year-old male Setting: Operating Room → ICU Clinical Context: Kevin Park is a 28-year-old male with no significant PMH presenting for elective anterior cruciate ligament (ACL) repair. He has no known allergies and no family history of anesthesia problems that
[NURSE'S NOTES] Patient: Renata Osei, 42-year-old female Setting: Psychiatric Unit → Medical ICU Clinical Context: Renata Osei is a 42-year-old female with bipolar I disorder, well-controlled for 6 years on lithium carbonate 900 mg BID (therapeutic level 0.8 mEq/L, checked 3 months ago). PMH: hypert
[NURSE'S NOTES] Patient: Baby Olivia Chen, Neonate — 18 hours of life Setting: Mother-Baby Unit / Neonatal ICU Clinical Context: Baby Olivia Chen is an 18-hour-old female neonate, born at 38+5 weeks via vaginal delivery to a 29-year-old G2P2 mother (Lily Chen). The delivery was uncomplicated, Apgar
[NURSE'S NOTES] Patient: DeShawn Miller, 34-year-old male Setting: Medical-Surgical Unit Clinical Context: DeShawn Miller is a 34-year-old male with sickle cell disease (HbSS) who is admitted for an elective red blood cell exchange transfusion to reduce HbS from 82% to <30% before an upcoming laparo
[NURSE'S NOTES] Patient: Gabriel Santos, 67-year-old male Setting: Wound Care Clinic → Medical-Surgical Unit Clinical Context: Gabriel Santos is a 67-year-old male with a 22-year history of type 2 diabetes (HbA1c 10.8%), peripheral artery disease (ABI 0.58 bilaterally), and peripheral neuropathy con
[NURSE'S NOTES] Patient: Miriam Goldstein, 72-year-old female Setting: Emergency Department Clinical Context: Miriam Goldstein is a 72-year-old female who presents to the ED via private car with her husband. She appears in significant distress, holding her right eye. Chief complaint: "Terrible pain
[NURSE'S NOTES] Patient: Terrence Cole, 16-year-old male Setting: Emergency Department Clinical Context: Terrence Cole is a 16-year-old male brought to the ED by his mother at 2:15 AM. He woke from sleep 2.5 hours ago with sudden onset of severe right scrotal pain. He denies trauma, sexual activity,
[NURSE'S NOTES] Patient: Florence Nakamura, 54-year-old female Setting: Medical-Surgical Unit Clinical Context: Florence Nakamura is a 54-year-old female with a 12-year history of alcohol use disorder (AUD) — drinks a fifth of vodka daily, last drink approximately 36 hours ago. She is malnourished (
[NURSE'S NOTES] Patient: Patricia Wells, 51-year-old female Setting: Cardiology Clinic → Emergency Department → Cardiac ICU Clinical Context: Patricia Wells is a 51-year-old female with a 6-year history of idiopathic pulmonary arterial hypertension (iPAH), managed on ambrisentan (endothelin receptor
[NURSE'S NOTES] Patient: Alejandro Vega, 72-year-old male Setting: Emergency Department Clinical Context: Alejandro Vega is a 72-year-old male with a history of atrial fibrillation (on warfarin, last INR 2 weeks ago was 1.6 — sub-therapeutic), hypertension, and prior MI (LAD stent 4 years ago). He p
[NURSE'S NOTES] Patient: Josephine Carter, 29-year-old female Setting: Labor and Delivery Unit Clinical Context: Josephine Carter is a 29-year-old G3P2 female at 34+4 weeks gestation admitted for painless vaginal bleeding. She reports waking from sleep with "a gush of bright red blood" that soaked t
[NURSE'S NOTES] Patient: Brianna Hayes, 34-year-old female Setting: Operating Room → PACU → Medical ICU Clinical Context: Brianna Hayes is a 34-year-old female with spina bifida (myelomeningocele, repaired at birth) undergoing elective laparoscopic bladder augmentation under general anesthesia. She
[NURSE'S NOTES] Patient: Winston Okafor, 22-year-old male Setting: Emergency Department → Trauma ICU Clinical Context: Winston Okafor is a 22-year-old male collegiate football player who was struck helmet-to-helmet during a game. He was found face-down on the field, unable to move his arms or legs.
[NURSE'S NOTES] Patient: Hazel Nguyen, 19-year-old female Setting: Medical-Psychiatric Unit Clinical Context: Hazel Nguyen is a 19-year-old female with a 4-year history of anorexia nervosa (restricting type), admitted via the ED after her parents found her collapsed at home. She is a college freshma
[NURSE'S NOTES] Patient: Omar Khalil, 38-year-old male Setting: Emergency Department → Medical ICU Clinical Context: Omar Khalil is a 38-year-old male who presents with a 3-week history of progressive dyspnea, nonproductive dry cough, low-grade fever, and profound fatigue. He lost 22 lb over the pas
[NURSE'S NOTES] [H&P] [VITALS] [LABS] [OB HISTORY] [ORDERS] [H&P] Ms. Dominique Washington is a 34-year-old Black woman, G4P3, at 36 weeks and 2 days gestation, admitted to Labor & Delivery for her scheduled repeat cesarean section. She has had three prior cesarean deliveries (the last two
The nurse reviews Mr. Okafor's admission data: blood glucose 740 mg/dL, Na 148 mEq/L, serum osmolality 328 mOsm/kg, BUN 32, creatinine 1.6, no urine ketones, BP 98/60 mmHg, HR 118 bpm, GCS 13, dry mucous membranes, poor skin turgor. He has T2DM, HTN, and CKD stage 2. Which findings are PRIORITY conc
The nurse completes the admission assessment for Mrs. Chen, 74-year-old female with COPD (GOLD II) and heart failure (EF 40%). Findings: SpO2 88% on room air, RR 26, HR 102, BP 136/84, T 38.9C, productive cough with yellow-green sputum, right lower lobe crackles and dullness to percussion, WBC 14,80
Ms. Williams, 29-year-old G2P2, delivered vaginally 1 hour ago after an 18-hour labor. The nurse assesses: fundus boggy and displaced to the right, lochia rubra heavy (2 pads soaked in 15 minutes), BP 92/58 mmHg, HR 124 bpm, skin pale and diaphoretic, estimated blood loss 650mL at delivery, urine ou
Tyler Rodriguez, 9-year-old male with known asthma on daily inhaled corticosteroids, is brought to the ED with 2-day worsening wheeze and shortness of breath. Assessment: T 37.2C, HR 118, RR 32, SpO2 91% on room air, using accessory muscles, tripod positioning, expiratory wheezing bilateral, PEFR 45
Mrs. Vasquez, 82-year-old female from assisted living, is brought to the ED by staff. She has new onset confusion, new urinary incontinence, T 38.4C, HR 108, BP 108/66 mmHg, RR 22. Labs: WBC 16,200, UA shows greater than 100 WBC/hpf, nitrite positive, many bacteria. Her baseline is alert and oriente
Marcus Thompson, 19-year-old male, presents to the ED with a 24-hour history of periumbilical pain that has migrated to the right lower quadrant. He rates pain 8/10, worse with movement. Assessment: T 38.3C, HR 102, BP 118/74, RR 18. Abdomen: rigid, rebound tenderness at McBurney's point, positive R
Ms. Delgado, 67-year-old female with HTN, T2DM, and CKD stage 2 (baseline Cr 1.4), underwent cardiac catheterization with contrast yesterday. Today's labs: Cr 2.8 mg/dL (up from 1.4), BUN 48, K+ 5.6 mEq/L, urine output 18 mL/hr over the past 4 hours. Current: BP 158/96, HR 88, no edema, no respirato
Mrs. Johansson, 44-year-old female with known Graves' disease, stopped her methimazole 3 weeks ago without consulting her provider. She presents to the ED brought by her husband who reports she has been 'acting strange' for 2 days. Assessment: T 39.8C, HR 148 (atrial fibrillation on monitor), BP 162
Mr. O'Brien, 52-year-old male with a 20-year history of heavy alcohol use, is brought to the ED by his roommate. He has not had a drink in approximately 36 hours after being unable to obtain alcohol. Assessment: T 37.9C, HR 118, BP 158/96, RR 20, diaphoretic, tremulous, CIWA-Ar score 18. He is confu
Ms. Osei, 31-year-old G3P2 at 34 weeks gestation with chronic hypertension on labetalol, presents to L&D triage with sudden onset severe abdominal pain described as 'board-like,' dark vaginal bleeding, and decreased fetal movement over the past hour. Assessment: T 37.1C, BP 158/102, HR 114, RR 20, u
Mrs. Okonkwo, 48-year-old female with BMI 34, presents to the ED with sudden onset severe epigastric pain radiating to the back, nausea, and vomiting for 8 hours. She denies alcohol use. Assessment: T 38.2C, HR 106, BP 104/68, RR 20, guarding in the epigastric region. Labs: lipase 1,840 U/L (normal
Baby Malik is a 3-day-old male, born at 38 weeks gestation to a 26-year-old G2P2 mother with blood type O-negative. Malik is blood type A-positive. He is exclusively breastfed. The mother reports he is 'very yellow' and feeding poorly (latching but falling asleep after 2 minutes). Assessment: jaundi
Mr. Rivera, 55-year-old male, is on post-operative day 5 following left total knee replacement. He was ambulatory yesterday. Today he reports sudden onset shortness of breath that woke him from sleep. Assessment: SpO2 89% on room air, RR 28, HR 116 (sinus tachycardia), BP 108/72, T 37.4C, left calf
Mr. Harris, 34-year-old male with bipolar I disorder, is brought to the psychiatric ED by his wife who reports he has not slept in 4 days, spent $12,000 on cryptocurrency without telling her, and has been 'talking a mile a minute.' Assessment: alert, oriented x3, speech is pressured and rapid, thoug
Mr. Bell, 28-year-old male, arrives via EMS following a motorcycle accident. He is immobilized on a long backboard with cervical collar in place. Assessment: GCS 15, alert, complaining of severe neck pain and inability to move his arms or legs. VS: BP 82/44 mmHg, HR 48 bpm, RR 18, SpO2 96% on 10L no
Mrs. Monroe, 72-year-old female with HFrEF (EF 30%), HTN, and atrial fibrillation on metoprolol, lisinopril, spironolactone, and digoxin, presents to the ED with 3-day worsening shortness of breath, 6-pound weight gain, and bilateral ankle swelling. Assessment: RR 26, SpO2 90% on room air, HR 96 (ir
Mr. Foster, 68-year-old male with HTN and atrial fibrillation (not on anticoagulation), is brought to the ED by his wife who found him on the floor at 0800. She last saw him normal at 0730. Current time: 0845. Assessment: GCS 11 (E3V3M5), right-sided facial droop, right arm and leg weakness (drift p
Sofia Martinez, 8-year-old female, is brought to the pediatric ED by her parents with a 12-hour history of severe headache, high fever, and neck stiffness. She has vomited three times. Parents report she has been increasingly difficult to arouse over the past 2 hours. Assessment: T 39.9C, HR 136, BP
Mr. Washington, 61-year-old male with CKD Stage 4 (GFR 22 mL/min), T2DM, and HTN, presents to the nephrology clinic for his quarterly visit. He reports fatigue, decreased appetite, leg cramps at night, and difficulty concentrating. Labs: creatinine 4.2 mg/dL (up from 3.8 three months ago), BUN 68, K
Mrs. Kowalski, 84-year-old female, is post-operative day 2 following right hip hemiarthroplasty for a femoral neck fracture. She has T2DM (Hgb A1c 9.2%), malnutrition (albumin 2.4 g/dL), urinary incontinence, and is minimally mobile. The nurse performs a Braden Scale assessment: Sensory Perception 2
Ms. Coleman, 26-year-old G1P0 at 35 weeks gestation, presents to L&D triage with a severe headache she rates 9/10, visual disturbances (flashing lights), and right upper quadrant pain. Her prenatal care was uncomplicated until today. Assessment: BP 168/112 mmHg (repeated x2), HR 96, RR 16, SpO2 98%.
Jordan Kim, 14-year-old male, is brought to the pediatric ED by his parents who report a 2-week history of polyuria, polydipsia, and 8-pound weight loss. Today he vomited twice and is breathing 'strangely.' Assessment: T 37.2C, HR 118, BP 98/62, RR 28 (deep, sighing respirations), SpO2 97%, fruity o
Mr. Park, 58-year-old male with T2DM (poorly controlled, A1c 10.4%) and rheumatoid arthritis on methotrexate and prednisone 10mg daily, presents with a 5-day history of progressively worsening left knee pain, swelling, warmth, and inability to bear weight. He reports no trauma. T 38.9C, HR 108, BP 1
Mr. Mendoza, 71-year-old male with known 5.8cm abdominal aortic aneurysm (AAA), hypertension, and 40-pack-year smoking history, is brought to the ED by ambulance after sudden onset severe tearing abdominal pain radiating to his back. He reports feeling 'like something ripped.' Assessment: BP 82/44 m
Ms. Torres, 35-year-old female, is transported to the burn center after a house fire. She was rescued after approximately 10 minutes in the burning structure. Assessment: Airway patent, voice hoarse, facial hair singed, soot around nares and mouth, carbonaceous sputum. Burns: face and neck (partial
Ms. Obi, 42-year-old female with known myasthenia gravis (MG) on pyridostigmine and prednisone, presents to the ED after 48 hours of worsening dysphagia, dysarthria, diplopia, and progressive bilateral ptosis. She reports she started azithromycin for a respiratory infection 3 days ago. Assessment: R
Mr. Park, 32-year-old male with no significant past medical history, is 20 minutes into an elective left knee arthroscopy under general anesthesia with sevoflurane and succinylcholine for intubation. The circulating nurse notes the following sudden changes: EtCO2 rising to 78 mmHg (was 38), temperat
Ms. Nair, 28-year-old female, is brought to the ED by her roommate 8 hours after reportedly ingesting 'the entire bottle' of acetaminophen (approximately 25g). She appears anxious but alert. Assessment: T 37.1C, HR 108, BP 118/74, RR 18, SpO2 99%. She reports nausea and right upper quadrant discomfo
Ms. Williams, 24-year-old female with HbSS sickle cell disease, presents to the ED with a 2-day history of severe bilateral leg pain (8/10) and lower back pain (9/10). She reports she has been sick with a URI for the past week. Assessment: T 38.4C, HR 112, BP 108/68, RR 22, SpO2 94% on room air. She
Mr. Brown, 55-year-old male with poorly controlled hypertension (on amlodipine 5mg, no other medications), presents to the ED after his home BP monitor read 218/136 mmHg. He ran out of amlodipine 5 days ago. Assessment: BP 224/140 mmHg (bilateral arms), HR 96, RR 18, SpO2 98%. Neurological: severe o
Mr. Okonkwo, 41-year-old male with HIV (CD4 count 180 cells/mm3, not on ART), presents with a 6-week history of productive cough, night sweats, 15-pound weight loss, and low-grade fever. He immigrated from Nigeria 8 months ago and has been living in a homeless shelter. Assessment: T 38.2C, HR 104, R
Ms. Patel, 29-year-old female with known Crohn's disease (terminal ileum involvement), presents with a 10-day history of worsening right lower quadrant pain, 8-10 bloody stools per day, fever, and 12-pound weight loss. She ran out of her infliximab infusion 6 weeks ago. Assessment: T 38.6C, HR 118,
Jake Morrison, 15-year-old male, is brought to the pediatric ED by his mother at 2:00 AM. He woke from sleep with sudden onset severe right testicular pain 2 hours ago. He has vomited twice. He denies trauma, sexual activity, and dysuria. Assessment: T 37.1C, HR 116, BP 136/84, RR 20. Right testicle
Ms. Chen, 32-year-old otherwise healthy female, presents with a 1-week history of easy bruising, petechiae on bilateral lower extremities and trunk, and one episode of epistaxis lasting 20 minutes. She reports a viral URI 3 weeks ago that resolved. No medications, no alcohol. Assessment: BP 118/74,
Mr. Watkins, 62-year-old male with ESRD on continuous ambulatory peritoneal dialysis (CAPD) for 3 years, calls the dialysis clinic reporting his dialysate effluent has been 'cloudy' for 2 days with new onset abdominal pain and low-grade fever. He is instructed to come in immediately. Assessment: T 3
Mr. Hayes, 34M with bee sting allergy, develops anaphylaxis with stridor, shock, and angioedema despite initial EpiPen. Requires repeat epinephrine, airway management, and biphasic observation.
Baby Noah, 6-week-old male with projectile non-bilious vomiting, weight loss, and hypochloremic hypokalemic metabolic alkalosis. Requires IV NS+KCl resuscitation before laparoscopic pyloromyotomy.
Mr. Rashid, 22M with closed tibial fracture developing ACS — opioid-resistant pain, tense compartment, paresthesia. Requires splint removal, emergency fasciotomy, rhabdomyolysis monitoring.
Ms. Petrov, 31F G2P1 at 39+2 weeks with diet-controlled GDM and macrosomic fetus. Develops intrapartum hyperglycemia and shoulder dystocia requiring McRoberts maneuver.
Mr. Osei, 58M with chronic HTN, develops tearing chest pain with BP asymmetry and intimal flap on CTA. Requires IV beta-blocker, BP control, and immediate cardiothoracic surgery.
Mrs. Barton, 67F with acute eye pain after dark theater. IOP 58 mmHg, mid-dilated pupil. Requires pilocarpine, IV acetazolamide, and laser peripheral iridotomy.
Ms. Brooks, 19F with anorexia (BMI 13.2) develops hypophosphatemia, hypokalemia, QTc prolongation 48hrs after refeeding. Requires feed reduction, IV electrolytes, cardiac monitoring.
Mr. Whitfield, 72M on warfarin (INR 3.8) with left basal ganglia hemorrhage. Requires 4F-PCC reversal, IV nicardipine, dysphagia assessment.
Mr. Simmons, 68M with GOLD III COPD, presents with purulent sputum, SpO2 84%, respiratory acidosis. Requires Venturi mask O2 titration, albuterol/ipratropium, corticosteroids, antibiotics.
Mrs. Jefferson, 74F with EF 32%, BNP 1240, bilateral crackles, JVD, edema. Requires IV furosemide, sodium restriction, GDMT initiation with ACEi/BB/MRA.
Ms. Monroe, 26F G1P0 at 20 weeks with cystitis progressing to pyelonephritis and urosepsis. Pregnancy-safe antibiotics, test-of-cure culture, sepsis recognition.
Mrs. Huang, 81F on apixaban with displaced femoral neck fracture. Post-op delirium, VTE prevention, hip precaution education, anticoagulation restart.
Mr. Torres, 38M heavy drinker with SAP, shock, Ranson criteria. Aggressive LR, thiamine before glucose, CIWA monitoring, infected necrosis management.
Ms. Cruz, 27F with PID history, ruptured right tubal ectopic. Massive transfusion, emergency salpingectomy, Rh status, therapeutic communication.
Mr. Webb, 31M with epilepsy, 22-min seizure after stopping levetiracetam. Second-line ASM, airway management, NCSE monitoring, medication adherence.
Mr. Hassan, 55M POD2 after hemicolectomy with basilar atelectasis progressing to HAP. IS coaching, multimodal analgesia, pulmonary hygiene bundle.
Mr. Carter, 52M with new Stage 2 HTN, smoking, obesity, sedentary. Lisinopril + lifestyle education, ACE cough, NSAID interaction.
Mrs. Mills, 58F with HbA1c 8.9%, polyuria/polydipsia. Metformin initiation, complication screening, hypoglycemia management, foot care.
Mrs. Owens, 67F with COPD and RLL CAP. Levofloxacin, oxygen target 88-92%, treatment failure recognition, prevention education.
Ms. Kim, 42F with TSH 18.4, low T4, positive TPO-Ab. Levothyroxine titration, empty-stomach administration, calcium interaction.
Mr. Park, 44M with bilateral PE, RV dilation, elevated troponin. IV heparin, hemodynamic monitoring, progression to massive PE.
Mr. James, 61M with LAD occlusion, V1-V4 ST elevation. Door-to-balloon, aspirin/ticagrelor, post-PCI troponin, pulseless VT arrest.
Mr. Thompson, 69M with pneumonia-source septic shock. Cultures, antibiotics, LR resuscitation, norepinephrine, post-sepsis syndrome.
Mrs. Walsh, 78F with gastroenteritis-induced AKI on ACEi/HCTZ/metformin. Fluid resuscitation, medication holds, dilutional hyponatremia.
Mr. Allen, 56M with hematemesis and melena from NSAID/aspirin PUD. Resuscitation, urgent EGD, H. pylori testing.
Mrs. Vega, 66F with new AFib, CHA2DS2-VASc 4. Apixaban, metoprolol, medication access barriers.
Mr. Rivera, 54M with alcoholic cirrhosis, SBP, encephalopathy. Ceftriaxone, IV albumin, dilutional hyponatremia.
Ms. Santos, 34F vegetarian with menorrhagia. Oral iron technique, vitamin C, calcium interaction, GI side effects.
Mr. Chen, 38M with GAD-7 16. Sertraline + CBT, alcohol self-medication, relaxation techniques.
Mr. Brooks, 58M with NSTEMI from 90% LAD stenosis. DAPT, anticoagulation, post-PCI troponin washout.
Ms. Pierce, 67F with AF-related MCA stroke. tPA eligibility, BP management, dysphagia screening, secondary prevention.
Mr. Obi, 52M CKD with K+ 7.8, ECG changes. Sequential treatment, hypoglycemia monitoring.
Ms. Johnson, 31F PPH from atony. Sequential uterotonics, carboprost contraindication in asthma, tranexamic acid.
Ms. Monroe, 24F at 28 weeks with cervical change. Corticosteroids, nifedipine, magnesium neuroprotection, PPROM.
Ms. Ahmad, 29F with aborted attempt and severe depression. Inpatient safety, 1:1 observation, discharge planning.
Ms. Walsh, 26F with classic UTI. First-line antibiotics, phenazopyridine, recurrence prevention strategies.
Mr. Bennett, 62M with recurrent gout. Low-dose colchicine, ULT timing, HCTZ→losartan, dietary modification.
Mr. Asante, 47M with pneumonia-ARDS P/F 72. ARDSnet LTV, PROSEVA proning, ET tube safety, PICS education.
Mr. Young, 26M first-episode psychosis. Risperidone, acute dystonia, delusional communication, family prodrome education.
Mr. Santos, 41M with lipase 4820, SIRS. Aggressive LR, hypocalcemia monitoring, infected necrosis, step-up approach.
Mr. Reeves, 32M heroin OD. Naloxone titration, COWS-guided buprenorphine, naloxone rescue kit, MAT engagement.
Emma, 18-month-old with SFS. No LP/EEG needed, parent first aid, prolonged seizure emergency.
Mrs. Kim, 64F T-score -2.8 on steroids. Bisphosphonate technique, calcium timing, AFF warning signs.
Mr. Foster, 58M pre-op TKR. NPO violation, metformin this morning, surgical site verification, post-op atelectasis.
Mrs. Okafor, 55F chronic LBP on oxycodone. Unexpected benzodiazepine, multimodal revision, combined overdose.
Mr. Dawson, 68M GOLD IV COPD with RV failure. Controlled O2, careful diuresis, LTOT, O2 order clarification.
Ms. Ng, 38F with ACTH-secreting microadenoma. Surgery, post-op cortisol replacement, sick-day rules, adrenal crisis.
Mr. Park, 29M C5 SCI with AD from Foley obstruction. Upright position, trigger removal, atropine contraindicated.
Marcus, 6M with nephrotic syndrome. Corticosteroids, home urine dipstick, pneumococcal vaccination, aggressive diuresis contraindicated.
Mrs. Hendricks, 65F post-THA with proximal DVT progressing to PE. Anticoagulation escalation, IVC filter non-essential.
Mrs. Foster, 34F with TSI-positive Graves. Methimazole + propranolol, three treatment options, agranulocytosis emergency.
Sophie, 11F newly diagnosed T1DM. Insulin technique, hypoglycemia management, school safety, sick-day rules.
Mr. Walker, 66M GOLD II COPD. Tiotropium, rescue vs controller, inhaler technique correction, COPD action plan.
Ms. Diane Okafor is a 48-year-old African American female with stage III ER/PR-positive, HER2-negative invasive ductal carcinoma of the left breast. S...
Marcus Hayes is a 21-year-old college junior brought to the psychiatric emergency department by his roommate. Over the past 6 weeks, Marcus has become...
Ms. Priya Nair is a 28-year-old South Asian female with a 5-year history of SLE managed on hydroxychloroquine 400 mg daily and prednisone 5 mg daily (...
Mrs. Gloria Hernandez is a 78-year-old Hispanic female admitted 2 days ago for an elective right total hip arthroplasty (THA) following a 2-year histo...
Mr. Earl Watkins is an 81-year-old African American male brought to the primary care clinic by his daughter, Cheryl. She reports that her father has f...
Mrs. Keiko Tanaka is a 52-year-old Japanese American female who underwent a total thyroidectomy 18 hours ago for papillary thyroid carcinoma. She is o...
Mr. David Torres, a 52-year-old male, presents to his primary care clinic for a routine physical. He reports increased thirst, frequent urination (app...
Ms. Priya Patel, a 28-year-old female, presents to her primary care provider reporting fatigue, weight gain of 15 pounds over 4 months despite no chan...
Mrs. Eleanor Witten, an 82-year-old female, is admitted to the orthopedic unit after undergoing right hip hemiarthroplasty (femoral head replacement) ...
Mr. James Holloway, a 34-year-old male, is voluntarily admitted to the inpatient psychiatric unit following a visit to his primary care provider, wher...
A community health nurse is running a free blood pressure screening clinic at a local community center in a low-income neighborhood. The clinic serves...
Mr. Samuel Greene, a 76-year-old male with a history of type 2 diabetes, peripheral vascular disease, and chronic heart failure (EF 35%), is admitted ...
A 12-month-old male, Noah Rodriguez, presents with his mother for his 12-month well-child visit. He was born full-term with no complications (birth we...
Mrs. Rosa Carvalho, a 69-year-old female with a history of ischemic stroke 10 days ago, is on a medical-surgical unit. Her stroke caused dysphagia (di...
Mr. Anthony Bello, a 55-year-old male, returns to the surgical unit from the PACU (Post-Anesthesia Care Unit) following an uncomplicated elective lapa...
Ms. Keisha Monroe, a 26-year-old G2P1, presents to Labor and Delivery at 39 weeks and 2 days gestation with regular contractions every 4–5 minutes las...
Mr. Harold Pierce, a 68-year-old male with a 40 pack-year smoking history and a known diagnosis of COPD (GOLD Stage III — severe), presents to the ED via ambulance after his wife called 911. She reports he has had worsening shortness of breath, increased sputum production (yellow-green, thicker than usual), and a productive cough for the past 3 days. He has been using his albuterol rescue inhaler every 2 hours without relief. He smokes 1 PPD and has not been vaccinated for influenza this season. Medications at home: tiotropium (Spiriva) inhaler daily, fluticasone/salmeterol (Advair) inhaler twice daily, albuterol (ProAir) PRN. Allergies: sulfa drugs (rash). Vital signs: BP 148/86 mmHg, HR 108 bpm, RR 28/min, Temp 38.4°C, SpO₂ 82% on room air. Auscultation: diffuse expiratory wheezing, prolonged expiratory phase, distant breath sounds bilaterally, use of accessory muscles. ABG on room air: pH 7.34, PaCO₂ 58 mmHg, PaO₂ 48 mmHg, HCO₃ 30 mEq/L. CXR: hyperinflation, flattened diaphragms, no infiltrate.
Mrs. Patricia Okafor, a 71-year-old female with a history of atrial fibrillation (on apixaban — last dose yesterday morning), hypertension, and hyperlipidemia, is brought to the ED by her husband at 9:15 AM. He reports she was 'perfectly fine' at breakfast at 8:45 AM and suddenly developed slurred speech and could not lift her right arm while clearing the table. Time last known well (LKW): 8:45 AM. Current time: 9:20 AM — symptom onset 35 minutes ago. Neurological exam: right facial droop, right upper extremity (RUE) weakness (4-/5 strength), slurred speech (dysarthria), mild right leg weakness. NIHSS (National Institutes of Health Stroke Scale) score: 9. Vital signs: BP 188/104 mmHg, HR 76 bpm (irregular), RR 16/min, Temp 36.9°C, SpO₂ 97% on room air. Fingerstick glucose: 142 mg/dL. CT head (non-contrast): no hemorrhage, no early ischemic changes. Platelet count: 218,000. INR: 1.1. The stroke team is activated.
Ms. Destiny Johnson, a 24-year-old female, presents to the urgent care clinic with wheezing, chest tightness, and shortness of breath that started approximately 2 hours ago. She was at a friend's apartment where there was a cat — she has a known cat allergy. She has a history of persistent moderate asthma and uses fluticasone (Flovent) 110 mcg inhaler twice daily (maintenance) and albuterol (ProAir HFA) PRN. She has not used her fluticasone for the past week ('I ran out'). She used her albuterol 3 times in the last 2 hours with minimal relief. She has no fever. Vital signs: BP 122/78 mmHg, HR 110 bpm, RR 24/min, Temp 37.0°C, SpO₂ 93% on room air. Peak expiratory flow rate (PEFR): 55% of personal best. Auscultation: diffuse bilateral expiratory wheezing, prolonged expiratory phase. She is speaking in short phrases and appears anxious.
Mr. Roberto Sanchez, a 64-year-old male with a 15-year history of type 2 diabetes and hypertension, is seen in the nephrology clinic for management of stage 3b chronic kidney disease (CKD). His most recent labs: eGFR 32 mL/min/1.73m², serum creatinine 2.4 mg/dL, BUN 38 mg/dL, potassium 5.4 mEq/L, sodium 138 mEq/L, bicarbonate 19 mEq/L, phosphorus 5.8 mg/dL, calcium 8.4 mg/dL, hemoglobin 10.1 g/dL, hematocrit 30%, albumin 3.4 g/dL, urine albumin-to-creatinine ratio (UACR) 380 mg/g (severely elevated). Current medications: lisinopril 10 mg daily, amlodipine 5 mg daily, metformin 1000 mg BID, atorvastatin 40 mg daily. BP today: 146/88 mmHg. He reports fatigue, mild ankle edema bilaterally, and decreased appetite. He asks, 'How serious is my kidney disease and what can I slow it down?'
Ms. Aisha Goldberg, a 32-year-old female, presents to the emergency department via walk-in, visibly distressed. She reports her heart is 'pounding out of her chest,' she feels short of breath, is trembling, and believes she is 'about to die.' She is hyperventilating (RR 32/min). She reports this started suddenly 15 minutes ago while at the grocery store and has happened 3–4 times over the past month. She has been afraid to go out of the house since the last episode. PMH: mild persistent asthma (on fluticasone and albuterol PRN, last albuterol use 2 weeks ago), no cardiac history. Her mother has generalized anxiety disorder. Current medications: fluticasone inhaler daily, albuterol PRN. Allergies: penicillin (hives). Vital signs: BP 142/90 mmHg, HR 118 bpm, RR 32/min, Temp 37.1°C, SpO₂ 99% on room air. ECG: sinus tachycardia, no ischemic changes. Troponin and D-dimer: normal. CXR: normal. Fingerstick glucose: 96 mg/dL. The emergency physician diagnoses a panic attack in the context of likely panic disorder.
Baby girl Monroe, a 36-hour-old female neonate born at 38 weeks gestation via uncomplicated vaginal delivery to a 28-year-old G1P1 mother (blood type O positive). Baby's blood type: A positive. APGAR scores: 8 at 1 minute, 9 at 5 minutes. Birth weight: 3,320 g (7 lb 5 oz). She has been breastfeeding, though the mother reports the baby is 'sleepy and hard to wake up for feeds' — she has fed only 3 times in 24 hours. At 36 hours of age, the nurse observes yellow discoloration of the sclera and skin (jaundice to the chest level). Vital signs: HR 148 bpm, RR 44/min, Temp 37.0°C axillary, SpO₂ 98%. Total serum bilirubin (TSB) level: 13.2 mg/dL at 36 hours of age. The Bhutani nomogram plots this in the HIGH-RISK zone for her gestational age and age in hours. Transcutaneous bilirubin check before the blood draw was 12.8 mg/dL.
A busy medical-surgical unit has a nurse preceptor (RN, 8 years experience) orienting a new graduate nurse (NGN) on day 3 of orientation. The unit cares for patients with a variety of medical diagnoses. The following scenarios occur during the shift. Patient 1: Mr. Henry Bloom, 78-year-old male, prescribed: insulin glargine (Lantus) 20 units SQ at bedtime AND insulin lispro (Humalog) sliding scale AC meals. Patient 2: Mrs. Clara Nguyen, 65-year-old female, prescribed: heparin 5,000 units SQ q8h for DVT prophylaxis. Patient 3: Mr. Tyler Ross, 52-year-old male, prescribed: metoprolol succinate (Toprol-XL) 50 mg PO daily AND metoprolol tartrate (Lopressor) 25 mg PO q6h PRN for HR >100 bpm. The preceptor uses each patient encounter to teach high-alert medication safety principles.
It is 7:30 AM on a busy 28-bed medical-surgical unit. The charge nurse (RN, 5 years experience) is managing the unit for the day shift. The staffing for the day is: 4 RNs (each caring for 6 patients), 1 licensed practical nurse (LPN/LVN), and 2 unlicensed assistive personnel (UAPs/CNAs). The unit has the following patient situations arising simultaneously at the beginning of the shift: (1) Room 101 — Mr. Adams, 72-year-old post-op day 1 after bowel resection, calling light on, reports his pain is 8/10 and he feels nauseated. (2) Room 108 — Ms. Bell, 58-year-old with pneumonia, SpO₂ has dropped from 95% to 88% on 2L NC per the oncoming nurse's report. (3) Room 115 — Mrs. Chen, 84-year-old with dementia, standing at the side of her bed trying to climb over the rail — fall risk. (4) Room 122 — Mr. Davis, 45-year-old stable with controlled hypertension, requesting his morning bath.
Mr. William Carver, a 79-year-old male with metastatic pancreatic cancer (diagnosed 8 months ago), is admitted to the inpatient palliative care unit at his own request following a goals-of-care conversation with his oncologist and palliative care team. He and his family have decided to pursue comfort-focused care — no further chemotherapy, no CPR (DNR/DNI order on file), no ICU admission. He has an advance directive naming his daughter, Sarah, as healthcare proxy. He is alert and oriented, though increasingly fatigued. His primary symptoms: severe pain (7/10, poorly controlled at home on oxycodone 10 mg q4h), nausea, decreased appetite, and profound fatigue. He reports his biggest fear is suffering in pain at the end. His wife and three adult children are present. He has been a farmer his whole life and describes his faith as 'very important' to him.
Mrs. Fatima Al-Rashid, a 30-year-old G3P3, is on the mother-baby unit 12 hours after an uncomplicated vaginal delivery of a 3,650 g (8 lb 1 oz) male infant at 39 weeks gestation. Labor lasted 8 hours; she received an epidural. She had a second-degree perineal laceration repaired with absorbable sutures. Estimated blood loss at delivery: 350 mL. She is exclusively breastfeeding. Her husband is present and involved. Vital signs: BP 118/72 mmHg, HR 76 bpm, Temp 37.3°C, RR 16/min. Current assessment findings: Uterus firm, midline, at the umbilicus; lochia rubra, moderate (saturating 1 pad per 3 hours); perineum — mild edema, slight ecchymosis, sutures intact; breasts — slightly engorged bilaterally, no cracking or redness of nipples; baby feeding at breast every 2–3 hours with audible swallowing; Homan's sign — negative bilaterally; lower extremities — 1+ pitting edema bilaterally. She reports pain 3/10 at the perineum and is asking when she can go home.
A 34-year-old female with a 3-year history of Graves' disease presents to the ED 9 days after self-discontinuing methimazole 20 mg BID due to cost. Chief complaints: palpitations, diaphoresis, agitation, and vomiting x 24 hours. Vitals on arrival: T 40.2°C (104.4°F), HR 168 irregular, BP 162/58, RR 32, SpO2 94% room air. Exam: diffuse goiter with thrill and bruit, mild bilateral proptosis, tremor, warm moist skin. Burch-Wartofsky Point Scale is being calculated. Labs pending include TSH, free T4
A 42-year-old male with a documented penicillin allergy (reported as rash) is on the pre-operative surgical unit awaiting elective cholecystectomy. Two minutes after cefazolin 2g IV infusion begins for surgical prophylaxis, the nurse performs a rapid head-to-toe assessment. Vital signs: BP 72/40 mmHg, HR 128 bpm, RR 28 breaths/min, SpO2 94% on room air.
Complete the Bow-Tie clinical reasoning diagram for a 29-year-old male in status epilepticus. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 22-year-old female with acute acetaminophen toxicity. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 19-year-old male with suspected compartment syndrome. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Admission assessment: BP 178/112 mmHg (repeated 15 minutes later 176/110), HR 98, RR 20, T 37.0 C, SpO2 97% on room air. The patient reports a severe occipital headache rated 8/10 that is unrelieved by acetaminophen, and describes intermittent blurred vision and 'spots' in her visual fields. Urine dip 3+ protein, spot protein/creatinine ratio 0.45. Labs: platelets 89,000/uL, AST 186 U/L (baseline 18), ALT 142 U/L (baseline 15), serum creatinine 1.1 mg/dL (baseline 0.6), LDH 312 U/L, uric acid 7.
Complete the Bow-Tie clinical reasoning diagram for a 26-year-old male presenting with acute neurological crisis after recent antipsychotic initiation. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
The patient was pulled from a house fire approximately 45 minutes ago. Primary survey is complete; she is hemodynamically borderline (HR 128, BP 100/72) and normothermic after external rewarming. The burn team is performing a systematic depth and TBSA assessment using the American Burn Association (ABA) Rule of Nines and Lund-Browder chart for documentation. On exam: the ENTIRE anterior thorax and abdomen (9% + 9% = 18%) show dry, leathery, charred-white eschar that is insensate to pinprick and
Complete the Bow-Tie clinical reasoning diagram for a 38-year-old male with acute neurological deterioration. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 58-year-old male with acute gastrointestinal hemorrhage. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 32-year-old postpartum patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
An 8-month-old male is brought to the emergency department by his parents. Mother reports the infant has had episodes of sudden inconsolable screaming approximately every 15-20 minutes for the past 8 hours, during which he pulls his knees up to his chest and becomes pale and diaphoretic. Between episodes, the infant appears limp and lethargic. He has vomited four times, with the most recent emesis appearing green-tinged. Twenty minutes ago he passed a stool described by the mother as 'red and sl
Complete the Bow-Tie clinical reasoning diagram for a 45-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 48-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 24-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 7-year-old female with status asthmaticus. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 52-year-old female with myasthenia gravis in crisis. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 72-year-old male with hyperosmolar hyperglycemic state. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 34-year-old male with tension pneumothorax. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 68-year-old female with acute decompensated heart failure and pulmonary edema. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 29-year-old pregnant woman at 36 weeks with known preeclampsia who develops a generalized tonic-clonic seizure in the labor room. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 3-year-old male with sudden onset high fever, neck stiffness, and rapidly spreading petechial rash. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 19-year-old male with Type 1 diabetes who ran out of insulin 2 days ago and presents with severe hyperglycemia, acidosis, and altered breathing pattern. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 44-year-old male with acute severe epigastric pain, elevated pancreatic enzymes, and hemodynamic instability. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 52-year-old male admitted with pneumonia who develops acute agitation, visual hallucinations, autonomic hyperactivity, and fever on hospital day 3 with a history of chronic heavy alcohol use. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and THREE parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 62-year-old male with COPD and spontaneous secondary pneumothorax. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
A 74-year-old female is transferred from a skilled nursing facility to the hospital after staff noted acute confusion, lethargy, and refusal to eat over the past 6 hours. She has a 3-day history of dysuria and urinary frequency. On arrival, BP does not improve after initial assessment. The ED physician activates the SEP-1 protocol.
Complete the Bow-Tie clinical reasoning diagram for a 30-year-old primigravida at term presenting with spontaneous rupture of membranes and acute fetal bradycardia. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 38-year-old female admitted after intentional acetaminophen overdose. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 66-year-old male with acute focal neurologic deficits and time-critical presentation. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
A 33-year-old G3P2 at 32 weeks gestation presents to labor and delivery with painless bright red vaginal bleeding that began 2 hours ago — she has soaked through 2 perineal pads. She denies abdominal pain, contractions, or ruptured membranes. Obstetric history: 2 prior uncomplicated vaginal deliveries. A prenatal ultrasound 2 weeks ago documented a complete placenta previa covering the internal cervical os. Vital signs: HR 112 bpm, BP 100/64 mmHg (baseline 118/76), RR 18, SpO2 98% on room air. A
Complete the Bow-Tie clinical reasoning diagram for a 26-year-old at 10 weeks gestation with severe nausea and vomiting. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 48-year-old post-operative day 3 with acute cardiopulmonary distress. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 4-week-old male with projectile vomiting. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for an unresponsive adult found on a park bench. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this gerontology patient. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this community health patient with infectious disease. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this leadership and delegation scenario. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this patient safety and transfusion scenario. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this complex prioritization and delegation scenario. Select the patient requiring immediate assessment, TWO priority nursing actions, and TWO parameters to monitor.
It is 0700 change of shift on a 28-bed medical-surgical unit. You are the charge nurse. Staffing for the 0700-1900 shift includes: yourself (RN, 8 years experience), two staff RNs (one with 3 years experience, one newly licensed 4 months out of orientation), one LPN/LVN (6 years experience), and two UAPs (unlicensed assistive personnel, both experienced). The unit has 22 clients at the start of shift. The outgoing night charge nurse gives you the following SBAR summary of assignment consideratio
A 34-year-old client arrives at the emergency department at 2200 accompanied by his sister. The triage note reads: "Brought in by family member — concerned about client's mental state after recent job loss and divorce. Client reluctantly agreed to come." The client is alert, oriented, and medically stable. Vital signs: BP 128/82, HR 88, RR 16, T 36.8°C, SpO2 98% on room air. The client's sister pulls the nurse aside and reports: "He lost his job three weeks ago and his divorce was finalized las
A 67-year-old woman is admitted to the medical unit with pneumonia. She is alert, oriented to person, place, time, and situation, and speaks English fluently. Her vital signs are: BP 132/78, HR 94, RR 22, T 38.6°C, SpO2 93% on 2L nasal cannula. The provider has ordered a peripherally inserted central catheter (PICC line) for administration of a two-week course of IV antibiotics after discharge to a skilled nursing facility. The IR (interventional radiology) department has sent up the informed c
An 82-year-old man has been hospitalized for 6 days with pneumonia complicated by sepsis. Despite aggressive treatment including broad-spectrum antibiotics, IV fluids, and vasopressor support in the ICU, his condition has progressively worsened. He has multi-organ dysfunction and is now on mechanical ventilation. A family meeting yesterday resulted in a decision to transition to comfort-focused care. Orders have been written for compassionate extubation and comfort measures this afternoon. The
You are a staff RN on a 0700-1900 shift on a medical-surgical unit. At 0945, you enter the room of a 58-year-old client who was admitted yesterday for cellulitis and started on IV vancomycin. You note that the client's IV pump is running. You look at the pump settings to confirm the next dose is infusing correctly, and you realize with alarm that the pump is programmed at 2000 mg/hour for a vancomycin dose of 2000 mg — meaning the full dose is being infused over 1 hour instead of the ordered 2-
A 78-year-old woman with a UTI and multiple fall risk factors is admitted for treatment. The nurse must establish the fall prevention plan.
The preoperative client is visibly anxious 2 hours before surgery and expresses fear about not waking up from anesthesia.
The oncoming nurse is receiving hand-off on a post-thyroidectomy client who recently received IV opioid analgesia.
The 2-week postpartum client describes symptoms that may be more than the typical baby blues.
An intubated ICU client has already partially self-extubated once and continues to reach for his endotracheal tube despite less restrictive interventions.
The client admitted for cellulitis related to IV drug use expresses anticipated judgment from healthcare providers.
The family of a dying client requests that specific religious and cultural practices be observed during and after death.
A nurse observes another staff member speak harshly to a confused older client who appears distressed by the interaction.
The evening nurse finds the hospitalized client with advanced dementia calling for her long-deceased mother and attempting to leave the unit.
A client with suspected active pulmonary tuberculosis is admitted and requires appropriate infection control precautions.
A 62-year-old male is admitted from the emergency department to the medical-surgical unit at 1430 with a diagnosis of community-acquired pneumonia. Past medical history: type 2 diabetes (A1C 7.2% at last check), hypertension, BMI 32. Medications at home: metformin, lisinopril, atorvastatin. No known drug allergies. ED workup: chest X-ray showed right lower lobe consolidation. WBC 14,500 with 12% bands. Lactate 2.1 mmol/L. He received one dose of IV ceftriaxone and azithromycin in the ED and 1 L
A 28-year-old G3P3 woman delivered a full-term female infant (birth weight 4,100 g) vaginally 45 minutes ago. Labor lasted 14 hours; the second stage was 2.5 hours. The delivery required a second-degree perineal laceration which was repaired. The placenta was delivered spontaneously 10 minutes after the infant and appeared intact. Pregnancy history: no significant complications. Labs on admission: hemoglobin 12.1, hematocrit 36%, platelets 210,000. Blood type O positive. Immediate postpartum v
An 11-year-old child is brought to the emergency department by parents. History from parents: the child has been 'not himself' for about a week — losing weight despite eating a lot, drinking excessive water (finishing a large bottle every hour or two), urinating frequently including two episodes of bedwetting after being fully continent for years. Over the past 24 hours, increasing fatigue, two episodes of vomiting, and labored breathing. No known medical history, no medications. Family history:
A 66-year-old right-handed woman is brought to the emergency department by her husband at 1145. Her husband states she was working in the garden when she suddenly sat down, and when he approached she could not speak clearly and her right arm went limp. He reports the last time she was clearly her normal self was at 1045, when they had coffee together — putting 'last known well' at one hour before arrival. Past medical history: hypertension, hyperlipidemia, atrial fibrillation (on warfarin, INR
A 58-year-old man arrives at the emergency department at 0815 by private vehicle, accompanied by his wife. He reports sudden onset of chest pain that began approximately 45 minutes ago while he was getting ready for work. He describes the pain as "crushing pressure, like someone standing on my chest," radiating to his left arm and jaw. Associated symptoms: shortness of breath, nausea, and sweating. He denies prior similar episodes. Past medical history: hypertension (on lisinopril), hyperlipide
A 32-year-old primigravida at 34 weeks gestation is brought to labor and delivery triage by her husband. She reports a 2-day history of worsening headache unresponsive to acetaminophen, blurred vision with "spots" in her visual field over the past 12 hours, and new right upper quadrant pain that began this morning. She also reports swelling of her face and hands over the past week. Prenatal history: unremarkable early pregnancy. Blood pressure trend: baseline 118/72 early in pregnancy; 140/88 a
A 68-year-old man with known severe COPD (FEV1 38% predicted on last pulmonary function testing) presents to the emergency department at 1930 via EMS. His wife reports he has had 'a cold' for the past 4 days with increasing cough, change in sputum from white to yellow-green, and steadily worsening shortness of breath. Today he became unable to complete sentences, appeared confused, and she called 911. Past medical history: severe COPD, former smoker (quit 5 years ago after 50 pack-year history)
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